Readers' letters - 19 July 2013

NHS needs change in culture and attitudes

We welcome the findings of the Liverpool Care Pathway and the emphasis on the need for significant investment in education and training of staff. However, as the review concluded, there is a need for culture and attitude change within the NHS that emphasises kindness and compassion.

Hospices are renowned for delivering high quality person-centred care for the dying. Hospice staff have developed competence and confidence in having difficult and respectful conversations with patients and their families over decades. Hospices have also developed educational structures to support the development of communication skills in others.

NHS staff need role models and opportunities to reflect on their own experiences and attitudes. The value of providing a safe and supportive learning environment in which to reflect and make sense of experience has been proven. St Christopher’s, one of the largest providers of palliative care education in the UK, has developed an innovative training course for clinical leaders from acute hospital settings.

Quality End of Life Care for All (QELCA) acknowledges the need for professionals to be shown ‘how to’ provide care to those who are approaching the end of life. The evidence suggests that this mode of education delivery changes attitudes and empowers practitioners to change not only their own practice but to lead change for their teams and within their organisations. A ‘training the trainers’ programme supported by Help the Hospices, the Department of Health and The Daisy Foundation has enabled 21 hospices to make partnerships with their local hospital to roll out the QELCA programme.

There are 220 hospice inpatient units in the UK. They are an untapped resource. The new local education and training boards should seek out hospices as a significant resource to influence culture change and practice in NHS settings.

Penny Hansford, director of nursing, Dr Nigel Sykes, medical director, St Christoper’s Hospice

Quality is as important as quantity

Your recent survey of trust HR Directors revealed some fascinating insights into their views – insights which tally with our own experience of current thinking about NHS workforces.

Particularly telling from our point of view was the respondents’ focus on quality of personnel as much as quantity. This is summed up by two key headline figures – the worrying 75 per cent saying the maintaining of high professional standards is not fit for purpose and the relatively low figure of 33 per cent not confident they have sufficient staff to meet service demands.

In our experience, nowhere is the need for investment of scarce HR resources more crucial than in the development of quality leadership throughout all levels of organisations – not just among senior management, important thought this is, but also crucially in terms of staff providing frontline services to patients.

Concentrating on this type of investment, via CPD and other initiatives, is the best hope the NHS has to squeeze more quality from declining resources at this challenging time of financial uncertainty. And it¹s all the more important if staff morale and positive employee relations are to be maintained and improved, in the way raised by NHS Employers chief executive Dean Royles in his comments on the survey.

The more progressive trusts have recognised this ­ and are acting accordingly ­ and your survey offers hope that others also acknowledge that the best way to implement Francis is to encourage and foster high-quality staff development and leadership ­ not just at the top but throughout organisations.

Neil Fineberg, Finegreen Associates Recruitment Consultants

Fixing the NHS is ‘fantasy’

I think it is a fantasy that someone “at the top” can fix the NHS. The underlying problematique facing the NHS has been years of reform that ministers and governments have never fundamentally committed to; they continue to seek opt-outs and ways to claw-back control. This is lack of commitment is evidence of policy failure extending over some years and not necessarily about leadership or dedication by clinicians and support staff within the NHS.

What reforms over the years have done is wind the NHS up more and more tightly so there is almost no room for people or organisations to manoeuvre, despite ministerial protestations that the reverse is actually happening. Strong institutional and clinical change cannot get any traction for fear of the consequences if something goes wrong. Fear not optimism prevails.

We all know that healthcare is a form of controlled chaos yet we design systems with the mistaken belief (fostered by people who should know better) that there are simple levers to pull or dials to spin that will make it all work better. Misunderstanding the nature of the system means politicians and advisors (expensive ones at that) are constantly solving very precisely the wrong problems. The result is what we see – organisational congestion, difficulty realigning services to better respond to patient needs, problems creating new organisations to deliver care (the dreaded contestability), with failures that cascade and escalate. A&E is on everyone’s mind, but hospitals should be adept at managing A&E (it is after all one of the main entrances to the NHS), even it means bolting on a primary care unit at the front end of the hospital, and bolting on a step-down unit at the other end. There are ways to do this and not beyond the ingenuity of people. There is no reason significant economies cannot also be realised to bend the cost-curve down, even in the face of rising demand.

The leadership fix is no guarantee – evidence from other industries shows the folly in putting faith in iconic notions of leadership; there are idiots out there too. People can handle only so much “culture” and “hug the team teddy” workshops and seminars, or people criss-crossing the NHS with their PowerPoint slide decks dispensing their wisdom.

The problems are real and compelling and require less, not more control, despite that sounding counter-intuitive. We need the locus of action with dedicated healthcare professionals and managers (yes, it is possible to define management as helpful and not obstructionist), positioned deep in the interactions with patients, enabling clinical and organisational arrangements to change and alter their structure easily. This also alters what would count as leadership.

Michael Tremblay, director, Tremblay Consulting